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Health care-associated infection in Africa

Health care-associated infection (HAI) is a major global safety concern for both patients and health-care professionals. These infections, often caused by multi-resistant pathogens, take a heavy toll on patients and their families by causing illness, prolonged hospital stay, potential disability, excess costs and sometimes death. The burden of HAI is already substantial in developed countries, where it affects from 5% to 15% of hospitalized patients in regular wards and as many as 50% or more patients in intensive care units (ICUs). In developing countries, the magnitude of the problem remains underestimated or even unknown, largely because HAI diagnosis is complex and surveillance activities to guide interventions require expertise and resources.

Among its core objectives, the Clean Care is Safer Care (CCiSC) programme (http://www.who.int/gpsc/en) aims to identify the burden of HAI worldwide, in particular in data-poor settings in low- and middle-income countries. The team, in collaboration with the WHO Collaborating Centre on Patient Safety (Infection Control and Improving Practices) undertook several systematic literature reviews to compile available data on the endemic burden of HAI worldwide. In particular, an original article was published in the Lancet (Allegranzi B. et al. The Lancet 2011; 377:228-41). A related WHO report was subsequently issued in May 2011.(http://www.who.int/gpsc/country_work/en/)

More importantly, part of this work actually focused on the African continent only and published in the October 2011 WHO Bulletin. As reported in this manuscript, only 19 papers from 10 African countries were published between 1995 and 2010 describing the epidemiology of HAI in health-care settings in Africa. HAI prevalence hospital-wide varied between 2.5% and 14.8%, up to twice as high as the average European prevalence (7.1%) reported by the European Centre for Disease Prevention and Control. Surgical site infection (SSI) was the most common type of infection, with reports indicating that up to three patients out of ten are affected by SSI. In developing countries, including many African ones, the HAI endemic burden is much higher in critically-ill patients admitted to intensive care units, where the incidence is at least three times higher than in high-income countries. Limited information was available on the impact of HAI in terms of cost, prolonged hospital stay and attributable mortality. However, surveys conducted in surgical wards clearly documented that patients affected by SSI had an increased hospital stay.

Some important aspects need to be considered when interpreting these findings. African settings able to conduct surveillance studies and publish data may have greater resources to implement infection prevention and control programmes than those who do not collect or publish data. Thus, the real burden of HAI is likely to be even greater in the many settings with weaker infrastructures and fewer resources across Africa. Despite some obstacles, there are also encouraging signs that the importance of HAI has started to be recognized in Africa. An Algerian study (Atif MN et al. Med Mal Infect 2006;36:423-8) documents how the introduction of a prevention programme at the facility level reduced the overall hospital-wide prevalence of HAI over five consecutive years. In Uganda, the implementation of a standardized protocol for surgical wound management dramatically reduced surgical site infection after caesarean section (Hodges AM, Agaba S. Trop Doct 1997;27:174-5).

Over the last five years, work conducted in collaboration with the WHO CCiSC team and WHO regional and country offices has demonstrated that improving hand hygiene practices is feasible, effective and sustainable despite very limited resources in Mali (Allegranzi B et al. Infect Control Hosp Epidemiol 2010;31:133-41). Moreover, CCiSC strongly supported the development of infection control programmes in several countries; for example, a national programme to reduce HAI (Programme national de lutte contre les infections nosocomiales [PRONALIN]), has been established in Senegal since 2004 and has become a catalyst for similar programmes in other countries in the region. Important stakeholders and partners are the Infection Prevention and Control African Network (IPCAN) and the Réseau international pour la planification et l’amélioration de la qualité et de la sécurité dans les systèmes de santé en Afrique (RIPAQS) that coordinate regional and international efforts to promote infection control and patient safety throughout the region. Through conferences and workshops organized by these networks, dissemination of the WHO Patient Safety and CCiSC concepts, strategies and tools has reached a broad range of health-care settings, government bodies, patient organizations and civil society in many African countries. The next appointment is in Namibia for the 3rd IPCAN Conference from 31 October to 3 November 2011, where CCiSC and APPS (African Partnerships for Patient Safety) workshops will be held (http://www.ipcan.co.za/conference-2011/information)

Initiatives such as those described above demonstrate that researchers, professionals and policy-makers have begun to consider HAI as a serious problem in Africa and that simple, low-cost interventions can be successfully implemented, despite the continent’s fragmented political and financial situation. These efforts need support and encouragement by WHO and other agencies and organizations. In light of the paucity of data highlighted by the CCiSC work, efforts to reduce HAI should begin with surveillance activities aimed towards estimating the burden of morbidity and mortality associated with HAI.